The Old Vicarage Care Home

The Old Vicarage Care Home is a residential care home providing personal care to up to 35 people. At the time of the inspection there were 16 people living in the home. The home is over two floors and there is a lift and stairs to the first floor. There is a lounge, dining room and visiting pod on the ground floor.

People’s experience of using this service and what we found

Since our last inspection, a new registered manager had begun working at the service. They had driven improvements to the culture of the service and provided leadership and better organisation. The provider had invested in making improvements to the premises. Governance systems had improved, which enabled the provider to have better oversight of risk within the service. We received positive feedback from everyone we spoke with in relation to how the service had improved.

Staff managed people’s medicines well and kept the home clean and tidy. Staff managed risks well and had plans to follow in case of emergencies. The service had systems to protect people from the risk of abuse and improper treatment. Staff were recruited safely and there were enough staff on duty to meet people’s needs. The premises were clean, tidy and safe.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The service met people’s nutritional needs and worked with them to make sure food provision also reflected their preferences. Staff supported people with their healthcare needs and worked well with external healthcare professionals. People were cared for by staff who were well supported and had the right skills and knowledge to meet their needs effectively, following good practice guidance.

People were treated well, with kindness and compassion by staff who respected their privacy and dignity and promoted inclusion.

The service put people at the heart of the care they received. Staff used detailed assessments to identify people’s needs and preferences and worked to ensure people were happy with the care they received. The service made sure people were supported to communicate and planned activities to enhance people’s wellbeing.

The registered manager had fostered a culture that was open and inclusive, and put people at the centre of the care they received. Staff understood their roles and responsibilities and worked well with external agencies to meet people’s needs. The provider monitored the quality of the service using a range of systems.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 25 August 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 25 August 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Recommendations

We have made a recommendation to the provider about gaining references from candidates’ previous employers, and about recording of best interests decision making.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Old Vicarage Care Home is a residential care home providing personal care to up to 35 people. At the time of the inspection there were 21 people living in the home. The home is over two floors and there is a lift and stairs to the first floor. The kitchen, dining room and laundry were all on the ground floor.

People’s experience of using this service and what we found

People were not in receipt of safe care at the time of the inspection. We saw when accidents or incidents occurred proper investigation did not take place, resulting in a lack of action to keep people safe. Good practices for medicines management were not adhered to as people did not receive their medicines as directed and medicines were not stored safely. Testing of key equipment including fire equipment was not completed. The provider had not recruited staff safely. The provider had not ensured enough trained staff were available to meet people’s needs and to implement their emergency evacuation plan.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

There had not been a stable management team at the home for some time and management procedures had not been followed. This included a lack of audit and monitoring of the service delivered to people. Staff did not feel supported and did not have the information they needed to deliver safe care. The provider had not operated an effective governance procedure to ensure action required to keep the building safe was taken when it was required and requirements under the provider’s registration including submitting notifications were not completed.

For more details, please see the full report which is on the CQC website at cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 12 September 2020). At our last inspection we recommended the provider reviewed the deployment of staff to ensure people’s needs were met. At this inspection we found this had not been effectively acted upon and the provider was found to be in breach of the associated regulation.

Why we inspected

The inspection was prompted in part due to concerns received about the safety of care and support people received. As a result, we carried out a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

We found the provider was in breach of regulations associated with safe care provided by enough staff who had been safely recruited and managed well by a competent management team. The provider had also not ensured notifications were sent to CQC as required. The provider took some immediate action to reduce associated risks, but we were concerned this had not led to timely improvements.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Old Vicarage Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed. We have identified breaches in relation to medicines management, infection control, suitable numbers of qualified and competent staff and a lack of effective oversight and quality audit systems, at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. We took enforcement action against the provider and issued a notice of proposal to remove the location from the providers's registration. The provider submitted representations and appeal against our decision stating improvements had been made sufficient to meet the requirements of the regulations. We re-inspected the service on 9 and 21 February 2023 and found sufficient improvement had been made to withdraw our decision.

We found the following examples of good practice.

People living at The Old Vicarage and staff were tested regularly for COVID-19, in line with government guidance. The service followed guidance for isolation when positive results were confirmed. Staff had received a full course of vaccination in line with requirements.

The service was mostly clean and maintained. However, we noted some areas where high-level dusting was required and waste bins which were not pedal operated and without lids. Domestic staff were employed to ensure levels of cleanliness and hygiene remained high. Staff followed written schedules for cleaning each area of the home. Completion of cleaning was monitored by senior staff.

Staff had received training around COVID-19 and how to work safely in a care home environment during the pandemic. We observed staff used personal protective equipment (PPE) appropriately. The service had ample stocks of PPE.

The provider’s infection control policy and procedures helped to ensure the service adopted best practice which followed current guidance. The provider used audits to monitor compliance with their polices.

The service facilitated safe visiting in line with current guidance. The service also supported people to maintain contact with their loved ones via telephone and video calls. This helped to aid people’s emotional and psychological wellbeing.

The Old Vicarage Care Home has two lounges and a dining room, and a lift is available to support people with mobility needs to access the second floor. There is also a garden area and a car park at the home.

People’s experience of using this service and what we found

The service had addressed the issues from the last inspection, and we found medicines were managed safely across the home. Auditing systems identified if improvements were required and care records reflected people’s needs and preferences. Documentation was completed to ensure people’s rights were upheld if restrictions were in place.

Recruitment procedures were followed to ensure staff were suitable to work with people who may be vulnerable. People were supported by staff who responded to their needs quickly. Two staff commented they felt additional staff at key times would be beneficial. We have made a recommendation about the review of staffing.

People said they were happy at the home and they liked the staff. People were cared for in a clean and homely environment by staff who were caring, competent and keen to improve the service provided. Risk assessments were carried out and staff could explain the reason for the assessments and how they followed them to help keep people safe.

The registered manager and staff worked with other agencies to help ensure people were the centre of their care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update. The last rating for this service was inadequate (published 09 June 2020) and there were three breaches of regulation. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since December 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 18 and 19 November 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Old Vicarage Care Home on our website at www.cqc.org.uk

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

Follow up

The overall rating for this service is requires improvement. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. In addition, we will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Old Vicarage Care Home is a residential care home providing personal care to 29 people aged 65 and over at the time of the inspection. The service can support up to 35 people.

The Old Vicarage Care Home has two lounges and a dining room, and a lift is available to support people with mobility needs to access the second floor. There is also a garden area and a car park at the home.

People’s experience of using this service and what we found

There is a history of non-compliance and people were at risk of avoidable harm. Medicines were not always managed safely which placed people at risk of harm. Care records did not always reflect discussions about people’s needs or the equipment they required to maintain their safety.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People could not be assured their rights were lawfully restricted as applications to the supervisory body did not always contain the restrictions in place. Auditing systems did not always identify the concerns found during the inspection.

People were supported by staff who knew them well and people shared they were happy with the staff provision. We received mixed feedback from staff about the number of staff available to support people at times. The environment was well maintained, and people told us they were happy with the cleanliness at the home.

Safe recruitment practices were followed to ensure staff were suitable to work with vulnerable people. Staff received training and supervision to maintain their skills.

People were supported to access external medical advice when this was needed, and people told us their care was discussed with them.

People were treated with dignity and respect and staff we spoke with told us how they respected people and ensured their privacy and dignity was maintained. People could express their end of life wishes if they wished to share these.

People gave positive feedback about the meals and snacks at the home. A varied menu was in place and people could choose alternatives if they wanted. People told us they were happy at the home and were confident any comments or complaints would be resolved. Relatives we spoke with also confirmed this.

People were consulted and asked their views on the service provided. The registered provider reviewed surveys completed by people and relatives to assess their satisfaction with the service. In addition, the registered manager had developed a survey with guidance from relatives, so they could focus on what relatives wanted to gain from a survey.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 06 July 2019) and there were two breaches of regulation. We took enforcement action to ensure the provider would improve. This inspection was carried out to follow up on action we told the provider to take at the last inspection. We have found evidence the provider needs to make improvement as not enough improvement had been made and sustained. Please see the safe, effective, responsive and well-led sections of this full report.

Why we inspected

This was a planned inspection based on the previous rating. This inspection was carried out to follow up on action we told the provider to take at the last inspection. We have found evidence that the provider needs to make improvement. Please see the safe, effective and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Old Vicarage on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner. We will also meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Old Vicarage Care Home provides personal care and support for up to 35 older people. At the time of the inspection 28 people were receiving support with personal care.

People’s experience of using this service:

Medicines were not managed safely which placed people at risk of harm.

People told us they received help from staff when they needed this and staff came quickly to support them.

People were enabled to express their views on their experiences of receiving care and support. People were encouraged to share their experiences of living at the home with staff and the management team.

Safe recruitment procedures were used to help ensure prospective employees were of suitable character to work at the home.

People told us they felt safe with staff and staff told us they would report concerns of abuse or avoidable harm to the manager and local safeguarding authorities to protect people.

Rating at last inspection:

At the last inspection the service was rated requires improvement (published 18 January 2019).

The service has been rated requires improvement for the last five consecutive inspections.

Why we inspected:

We carried out this focused inspection to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection in October 2018 had been taken.

Enforcement:

We have identified breaches in relation to management and oversight of medicines and in relation to the oversight and governance of the service. We have imposed conditions on the registration for this location to address the management and oversight of medicines.

Follow up:

We have asked the registered provider for an action plan to show how they will make and sustain improvements.

We will liaise with the local authority and clinical commission group to ensure all required actions are completed to ensure the health and welfare of people who live at the home.

The next scheduled inspection will be in keeping with the overall rating. We will continue to monitor information we receive from and about the service. We may inspect sooner if we receive concerning information about the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The Old Vicarage Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Old Vicarage Care Home is registered to accommodate a maximum of 35 older people, including older people who may be living with dementia. Accommodation is provided on two floors. A passenger lift is available. There is a communal lounge, a separate dining area and an enclosed garden.

At our last inspection in August 2017 the service was rated as ‘Requires improvement’. We identified a breach of Regulation 12 of the Health and Social Act Care Act 2008 (Regulated Activities) Regulations 2014. We found people could not be assured that medicines were managed safely as staff trained in medicines were not always available and infection control practices did not protect people from the risk and spread of infection. We also noted a breach of Regulation 18 of the Health and Social Act Care Act 2008 (Regulated Activities) Regulations 2014 as staff were not consistently available to meet people’s needs and staff were not always well rested. In addition, we identified a breach of Regulation 17 of the Health and Social Act Care Act 2008 (Regulated Activities) Regulations 2014 as care records were not always completed with up to date information about people’s individual needs. In addition, the audit systems in place had not identified the concerns we had found on inspection and if people raised concerns, these were not always continuously followed through and reviewed. We took regulatory action and served requirement notices for these breaches of legal requirements. We asked the registered provider to take action to make improvements to the areas we identified. The registered provider sent us an action plan which indicated improvements would be completed by November 2017.

At this inspection in October and November 2018 we found medicines were not always managed safely. For example, we found people could not be assured they would receive their medicines in a safe way, or when they needed them. This was a breach of Regulation 12 of the Health and Social Act Care Act 2008 (Regulated Activities) Regulations 2014.

You can see the action we told the provider to take in the full version of the report.

At this inspection in October and November 2018 we found the home had transferred paper care records to a computer based system. Records we viewed showed the care and support people required to meet their needs, however this was sometimes difficult to find. We have made a recommendation regarding this.

Relatives told us they were consulted and involved in their family members care. People we spoke with confirmed they were involved in their care planning if they wished to be and staff treated them kindly and with respect. Documentation we viewed did not consistently record people’s consent or involvement. We have made a recommendation regarding this.

Records related to the food people had eaten and the times they had bathed or showered were not consistently accurate, the manager and regional manager told us they had identified this as an area for improvement. Staff told us the manager discussed this with them to improve the record keeping at the home.

We found improvements had been made to manage the risk and spread of infection. We found the home was visibly clean and checks were carried out to ensure the environment remained hygienic.

We reviewed recruitment records to check staff were safely recruited. Staff told us recruitment checks were carried out prior to starting employment at the home. We noted one recruitment record did not contain a full employment history of a staff member. We discussed this with the regional manager and the manager. The regional manager could demonstrate how the service had changed its working processes to ensure this did not happen again.

Audits carried out by the manager and the regional manager had identified where improvements were required and action plans were in place to ensure steps were taken to improve the service provided.

The service sought feedback from people who lived at the home, relatives and visitors to identify what the home did well and what needed to improve. A notice board within the home displayed the findings of the feedback given and the action the home had taken.

People told us they did not have to wait for help and we timed two call bells which were answered promptly. We observed staff were patient and did not rush people when they supported them. Staff told us they considered the home was busy at times, but they could meet people’s needs promptly. Rotas we viewed showed staff had their rota arranged so they had adequate rest days and did not work excessive days in a row.

At the time of the inspection visit there was a no manager in place who was registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was a manager at the home who was supported by a deputy manager.

Staff told us and we saw documentation which evidenced staff attended training to enable them to maintain and update their skills. We also saw evidence and staff confirmed, they had regular supervision with their line manager to discuss their performance. The manager explained that in the last 12 months, a new staff team had started work at the Old Vicarage Care Home and appraisals were being planned.

People were asked to express their end of life wishes. Documentation was available to plan this area of people’s care if people wanted to share their needs and wishes.

People told us they had access to healthcare professionals and their healthcare needs were met. Documentation we viewed showed people were supported to access further healthcare advice if this was appropriate. People and relatives told us they were happy with the care at support provided at The Old Vicarage Care Home.

People told us they had a choice of meals to choose from and they enjoyed the meals provided. We observed the lunchtime meal. We saw people were given the meal of their choice and were offered more if they requested it. Staff were available to help people if they needed support.

Staff we spoke with knew the needs and wishes of people who lived at the home. Staff spoke fondly of the people they supported and said they cared about them and their wellbeing. Staff were gentle and patient with people who lived at the home and people told us they felt respected and valued.

Staff we spoke with were able to describe the help and support people required to maintain their safety and people who lived at the home told us they felt safe.

Staff told us they were committed to protecting people at the home from abuse and would raise any concerns with the registered provider or the Lancashire Safeguarding Authorities so people were protected.

There was a complaints procedure available at the home. People we spoke with told us they had no complaints, but they if they did these would be raised to the manager or staff.

People told us there were a range of activities provided to take part in if they wished to do so. People told us they were asked if they wanted to take part in activities and if they declined, their wishes were respected. Staff told us they reminded people of the activities available.

The manager demonstrated their understanding of the Mental Capacity Act 2005. People told us they were enabled to make decisions and staff told us they would help people with decision making if this was required. People were supported to have maximum choice and control in their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Relatives we spoke with told us they were could speak with the manager if they wished to do so and they found the manager approachable.

This is the fifth time the service has been rated Requires Improvement.

Further information is in the detailed findings below.

The Old Vicarage provides personal care for a maximum of 35 older people who may be living with dementia or a physical disability. The home is situated in a residential area of Freckleton village close to local shops and other amenities. There is full lift access to both floors to assist people with reduced mobility. Communal areas consist of a lounge, dining room and rear garden.

A registered manager was not in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 19, 26 and 27 April 2017, we rated the service as Requires Improvement. This was because breaches of legal requirements were found. The provider failed to ensure systems were in place to assess, monitor and improve the quality and safety of the service. These had not been established and operated effectively and records were not consistently accurate.

We additionally made recommendations for the provider to further improve people’s safety and welfare. These concerned systems to enhance safe medication recordkeeping, falls management, general risk assessments and staff training. We also recommended the provider developed their person-centred approach to care planning.

During this inspection, we found the provider continued to fail to maintain good governance and oversight at the home. Audits we looked at did not pick up the concerns we found during our inspection. Care records and monitoring systems were poorly organised and the management team failed to store them securely. We noted gaps in care records and people’s documented preferences were not consistently followed. We reviewed the management team’s staffing tool and found it did not always meet the requirements of people’s complex needs. Although people’s feedback was sought, the provider had not always followed identified concerns through. This is a breach of Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance.

You can see what action we told the provider to take at the back of the full version of the report.

Staff told us the management team were supportive in their work and personal issues. They felt a part of the drive to improve the home and were keen about developing the Old Vicarage further.

We found the provider had improved falls assessment and management processes. For example, they introduced new systems, which covered an outline of the accident, body mapping of any injuries and ongoing observation charts. Falls risk assessments were implemented to identify hazards and actions to reduce them. We noted one person’s fall was not properly documented and the management team assured us they would address this through staff training.

You can see what action we told the provider to take at the back of the full version of the report.

We noted staffing levels and skill mixes were insufficient and the deployment of employees was not always effective. For example, people’s meals were disrupted because there were not enough personnel to support them. We observed they had to wait to be supported with personal care. There were not enough trained staff to manage people’s medicines at night. A relative commented, “Staffing levels are horrific. Many times I’ve gone round looking for staff.” This is a breach of Regulation 18 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Staffing.

You can see what action we told the provider to take at the back of the full version of the report.

We found care records contained medication risk assessments and care plans, and staff administered recorded medicines safely. However, there were not always medication trained staff available 24 hours a day to monitor for potential side effects. People received their medication, including night sedation, too early in the evening. If they needed something during the night, the system in place was poor medicines management because there were potential delays in people’s treatment. This is a breach of Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe care and treatment.

You can see what action we told the provider to take at the back of the full version of the report.

On arrival, we looked around the premises and found multiple areas of concern with infection control practices. Carpets, furnishings and linen were dirty and stained and associated cleaning records had not been fully completed. We found a very strong odour throughout our inspection and people were dressed in stained clothes that were not changed. This is a breach of Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe care and treatment.

You can see what action we told the provider to take at the back of the full version of the report.

We found care plans contained detailed information about each person and their requirements. This guided staff, especially new employees, to people’s needs and their wishes about their support. We observed staff assisted those who lived at the home with compassion and courtesy. A relative said, “The staff are very kind to me.”

However, we saw people’s choices were not always followed. For example, a relative said their family member preferred female staff to support them with personal care, which was not consistently provided. We found missing information in records, such as fluid and food monitoring forms where there were gaps for hours at a time. This meant oversight of people’s needs was incomplete and inconsistent, which negatively affected the responsiveness of care delivery.

The cook ensured special diets, such as for medical conditions, allergies and soft meals, were catered for. However, two staff simultaneously supported three individuals who required assistance, which meant their meals were constantly disrupted. We received mixed comments about the quality of food provided.

Staff demonstrated a good understanding of protocols and reporting procedures related to safeguarding incidents. Training records we looked at confirmed they had completed relevant training.

Staff files we looked evidenced staff received training relevant to their roles. The management team reviewed potential employees’ full employment history and obtained required checks to ensure they recruited appropriate staff. This was followed by in-depth induction to support them in their new roles.

Staff demonstrated a good level of awareness of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Where people were deprived of their liberty to safeguard them, we found up-to-date records were in place. The person who lived at the home or their representative had signed their agreement to each area of their support plans.

The Old Vicarage is a residential care home accommodating a maximum of 31 older people including people who are living with dementia. Accommodation is provided on two floors. A passenger lift is available. There is a communal lounge, a separate dining area and an enclosed garden.

At the time of the inspection there was no manager in place who was registered with the Care Quality Commission. There was a manager in place who was in the process of applying to become the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We last inspected The Old Vicarage Care Home in October 2015. We identified a breach in Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and treatment.) We found medicines were not managed safely.

During this inspection carried out in April 2017 we found improvements had been made and medicines were managed safely. We have made a recommendation regarding best practice and the management of medicines.

Documentation we viewed was not always complete or up to date. We found risks to people were identified, however the action required to maintain people’s safety was not always recorded. In addition, we found care records were not always completed when care was delivered.

This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance.)

We looked at the auditing systems in place to identify shortfalls at the home and drive improvement. We found checks on medicines and the environment were carried out. We were informed that audits on care records were not currently carried out and during the inspection visit we noted improvements were required within care records. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance.)

We viewed the accident and incident audit and noted it had not identified if referrals to the local safeguarding authorities were required. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance.)

We observed care and support being provided in a safe way and people told us they felt safe. One person told us, “I’m being taken care of and I have someone come to my room every day.”

Staff were able to explain the actions to take if they were concerned someone was at risk of harm or abuse. People who lived at the home told us they felt safe. We found a number of falls had occurred at the home and they had not been referred to the local safeguarding authorities. We have made a recommendation regarding this.

We checked to see if people without mental capacity were lawfully deprived of their liberty if this was necessary. We found appropriate applications to deprive people of their liberty were made to the local authorities as required.

We reviewed staff files and found there were processes that ensured staff were suitably recruited. Staff we spoke with confirmed checks had been carried out prior to starting work at the home.

Staff told us they met with the manager on an individual basis to discuss their performance. Staff were complimentary of the training provided and told us further training was being arranged to ensure their skills remained up to date.

We discussed staffing with people who lived at the home. People and their relatives told us staff were often ‘busy.’ During the inspection we saw staff were patient and kind with people who lived at the home. We saw people were supported at a pace appropriate to their individual needs.

People who lived at The Old Vicarage Care Home told us they considered staff were caring. One person told us, “They’re marvellous, they’re really, really kind”.” We observed people being supported with kindness and compassion.

During the inspection we saw people took part in board games and activities which were meaningful to them. Relatives told us activities were not often provided and one person who lived at the home told us they were “Bored.” We discussed this with the regional manager. They informed us an activities co-ordinator had been recruited.

There was a complaints policy available at the home. People told us they would talk to staff if they had any concerns.

People told us they enjoyed the food at the home. We observed the lunchtime meal and saw this was a positive experience for people who lived at The Old Vicarage Care Home. Staff gently encouraged people to eat and we saw people enjoyed their meal.

People who lived at the home told us they could speak with the manager if they wished to do so. We saw meetings were held for people to express their opinions and surveys were offered to relatives and people who lived at the home. People who lived at the home and their relatives told us the manager was approachable.

People told us they were supported to see health professionals if the need arose and we found this was recorded in care documentation. We found that when people had experienced falls, people were referred to their doctor. We saw no evidence people were referred to a health expert who specialised in falls management. We have made a recommendation regarding this.

There were 24 people using the service at the time of the inspection.

At the time of the inspection the service did not have a registered manager in place. However, a new manager had been recruited and intended to apply for registration with the commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The last inspection of the service took place on 8 & 13 October 2015. During that inspection we found the service was in breach of a number of regulations relating to person centred care, consent, safe care and treatment, safeguarding people from abuse and improper treatment, meeting nutritional needs, good governance, staffing and recruitment.

We found during this inspection that a number of significant improvements had been made. However, we identified a number of areas where further improvements were required and we still had outstanding concerns about medicines management.

The overall management of medicines was much improved. We found that there were clear medicines records in place for each person who used the service, which included all the required information. We also noted that medicines were now stored in a safe and appropriate manner. However, during the inspection we found that some errors had occurred, which resulted in two people receiving their medicines at the wrong times and another person not receiving some medicine for a period of four days, because the stock had run out. This meant that people did not always receive their medicines as prescribed.

At the last inspection of the service carried out in October 2015, we found that risks to people’s safety and welfare were not always assessed or managed well. We found during this inspection that procedures for risk assessment and care planning were much improved and care workers had a good understanding of the measures required to promote people’s safety. However, we found that people’s individual risk management plans and PEEPS (Personal Emergency Evacuation Plans) could have contained more individualised guidance to further support their safe care and treatment. We made a recommendation about this.

During the last inspection in October 2015, we found that the provider did not always ensure there were adequate numbers of suitably qualified and competent staff on duty to meet people’s needs safely. During this inspection we found there had been much improvement to staff training and that staffing levels were determined in line with the needs of people who used the service. However, some people we spoke with told us they felt they had to wait for assistance at times and we also noted that staff were not always present in some communal areas of the home, such as the lounge. We made a recommendation that the manner in which staff are deployed across the service is reviewed.

We found recruitment procedures were more robust. The provider was able to demonstrate that due consideration was given as to whether applicants were suitably qualified to carry out the role they were applying for and all applicants were subject to a range of background checks to help ensure they were of suitable character. However, further potential improvements to the recruitment processes were needed.

Everyone we spoke with including people who used the service, their families and community professionals felt the home had been much cleaner since the last inspection. People were very satisfied with the standards of cleanliness and hygiene. A lead person had been appointed for the area of infection control and improved infection control procedures were in place. However, we did note some areas and equipment to be visibly unclean. In addition, some parts of the home were found to be malodorous.

At the last inspection in October 2015 we found that the service did not always obtain legal consent from people who used the service and we also found some examples where the service had failed to seek appropriate authorisations to make decisions on people’s behalf about their care and accommodation. During this inspection, we found that the service properly considered people’s mental capacity to consent and ensured that any decisions made on people’s behalf were done so with the correct authorisations. However, we found that information relating to people’s capacity and any authorisations in place, could have been better recorded in their care plans. We made a recommendation about this.

Most people felt that they received care that was person centred and that met their personal needs and preferences. In addition, people in general felt that staff at the home communicated well with them about their or their loved ones’ care. However, this was not the experience of everyone we spoke with. We made a recommendation that the manager consider the views of people who felt communication and opportunities to be involved in their care could be improved.

People reported positive experiences of care and told us they found the staff to be kind, caring and respectful. People also felt their privacy and dignity was respected. However, we found that some people’s privacy and dignity had been compromised, due to personal information about them being left in view within their bedrooms or en-suite facilities. We made a recommendation about this.

Arrangements for monitoring safety and quality across the service were much improved. We saw there were regular audits in place which were carried out on daily, weekly and monthly intervals. However, we found some examples where issues had been identified through the audit process, but had not been acted upon. We also found that audits were not always carried out with the correct timescales. We made a recommendation about this.

Staff understood the needs of the people they supported and worked well with external professionals to ensure people’s needs were met. We found evidence that staff recognised and responded well to people’s changing needs. People received effective nutritional care and were satisfied with the standard and variety of meals provided.

Staff were aware of their responsibility to protect people from abuse and improper treatment. There was a good system in place which enabled both the manager and provider to monitor adverse incidents, such as accidents or safeguarding concerns so that any themes or trends could be identified and addressed.

We found an ongoing breach of Regulation 12(2) (g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the management of people’s medicines. The action we told the provider to take can be seen at the back of this report.

We spoke with three residents who told us they were happy living at The Old Vicarage and said their needs were well met. One resident commented, ' I have no complaints. Everyone is very good to me here.' Another told us, ' I am more than happy. I am very well looked after. They (the staff) are all very good to me.'

We carried out this inspection to ensure that improvements had been made in the areas of infection control, medication management and quality assurance. The manager was able to describe actions she had taken to address the areas of none compliance we identified at our previous inspection. In addition, evidence was available to demonstrate that the improvements had been embedded into the working practices of the service, to help ensure they were maintained.

During the inspection, we examined the actions that had been taken by the provider to comply with the warning notice and assessed the improvements they had made.

We found that the provider had met the requirements of the warning notice. We will be carrying out further work with the service in the future, to ensure that they maintain the improvements made.

'They are brilliant! All great!'

'They look after us so well. I could not ask for anything more!'

'This place is brilliant. They are smashing!'

'I can't fault it here at all.'

We assessed a number of areas during this inspection, including how the care and welfare of people was promoted and how people's medication was managed. We also looked at the arrangements for safeguarding people from abuse and processes for monitoring quality. We found some examples of very good practice. However, we also identified some concerns, particularly in relation to arrangements for safeguarding people from abuse. We have asked the provider to take action to address our concerns and will be carrying out further work to ensure this has been completed.

A relative said, 'I am fully involved in decisions about mum's care.'

People were given appropriate and relevant information to enable them to understand their care and support options and to make informed decisions. A relative told us about a newsletter provided by the manager. They said, 'The last newsletter told us about end of life care and important things like the Liverpool Care Pathway. This helps us to make decisions about the care for our relative.'

We found that individual care plans and risk assessments were in place and that individual needs were being met. A relative told us, 'My mum has been nursed in bed for a while. She has never had any pressure sores because they use special boots and a mattress and they make sure she is moved every two hours. They also record everything she drinks so that she doesn't get dehydrated.'

We found that staff were trained and supported to provide safe and effective care to residents.

There was a suitable and sufficient range of equipment in place to safely meet people's needs and promote their independence.